Resident and Fellow Training in a Pandemic

Disease of the Year 2021: COVID-19 Section Editors: Bart K. Chwalisz, MD Marc J. Dinkin, MD Resident and Fellow Training in a Pandemic Scott N. Grossman, MD, Steven L. Galetta, MD, Andrew G. Lee, MD, Valerie Biousse, MD, Koto Ishida, MD Downloaded from http://journals.lww.com/jneuro-ophthalmology by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8K2+Ya6H515kE= on 05/04/2022 G rossman: To kick us off, you are both senior educators in neuro-ophthalmology and I wanted to ask generally how this past year, since COVID came to the United States in March 2020, has been different, better, worse, or the same as previous eras in neuro-ophthalmic education (1). Lee: We have morning report every day, and that used to be in-person. After the shutdown, our morning report became Zoom-only. The advantage of Zoom is that we now have 20 people on the Zoom, and we only used to be able to have 10 in the room. Morning report grew because more people could come. Our rounds also are Zoom. Even after the shutdown ended here in Houston, we still only have a ten-person limit for our auditorium, so we still use Zoom for Grand Rounds. Grossman: So it is an access thing, where you feel there is greater access for trainees to join in from different locations. How many locations does Blanton (Eye Institute) have? Lee: We have 4 medical schools—Baylor College of Medicine, Texas A&M, UTMB, and UT-Houston—so those sites are very disparately located, including Galveston, which is 40 miles away. It allowed more people to participate because of the distance. And we have remote learners who join in who are not actually at our medical school. Grossman: Dr. Galetta, how would you reflect on how things have changed at NYU for trainees during this period? Galetta: It was a dramatic change, because in March we had to quickly adjust to the avalanche of patients with COVID-19 and it resulted in moving the residents out of the outpatient clinics and they had to go into the hospital and help in the MICU and on the floors because virtually Departments of Neurology (SG) and Ophthalmology (SG, SLG), NYU Grossman School of Medicine, New York, New York; Department of Ophthalmology (AGL), Blanton Eye Institute, Houston Methodist Hospital, Houston, Texas; Departments of Neurology (AGL), Neurosurgery, and Ophthalmology, Weill Cornell Medicine, New York, New York; Department of Ophthalmology (AGL), University of Texas Medical Branch, Galveston, Texas; Department of Ophthalmology (AGL), University of Texas MD Anderson Cancer Center, Houston, Texas; Department of Ophthalmology (AGL), Texas A&M University College of Medicine, Houston, Texas; Department of Ophthalmology (AGL), Baylor College of Medicine and the Center for Space Medicine (AGL), Houston, Texas; Department of Ophthalmology (AGL), University of Iowa Hospitals and Clinics (AGL), Iowa City, Iowa; and Department of Ophthalmology (AGL), University of Buffalo (AGL), Buffalo, New York. The authors report no conflicts of interest. Address correspondence to Scott Grossman, Department of Neurology, NYU Grossman School of Medicine, 222 East 41st Street, 10th Floor, New York, NY 10017; E-mail: [e-mail] 6 every floor got converted to a COVID floor (2). It was all about Medicine at that time. Furthermore, their continuity clinics had to be converted to virtual experiences, and quite honestly, at our public hospital (Bellevue) that was a challenge at first. A lot of the interaction with patients was by telephone. That was in contrast to the NYU Clinical Practices that went from 0 virtual visits to over 200 a day, and the Medical Center went from 50 to 7,000 per day during the peak. From March to May, we saw 10,000 Virtual Visits (3,4). Those are some dramatic numbers. The fellows did video visits with the attending. Now, we could have done that remotely where we brought the fellow in, but the fellows and I largely sat next to each other to do it that way. Therefore telemedicine was a big part of the experience for the residents and fellows (5,6). Grossman: Looking beyond a time when COVID is an active issue in the United States, do you think that trainees should actively work toward cultivating a skill set in teleneuro-ophthalmology? Is that something we should really be focused on as trainees? Lee: In Houston, we have continued virtual visits although our shutdown ended. We still use it for followups that are check-ins. That has helped a lot because neuroophthalmology had a huge waitlist before, and we were able to compress it. Amazingly, we can do a virtual at-home visual acuity and a visual field, and we have adapted some approaches for eye movements and pupils. During our shutdown the medical students were not allowed to come, so we had ‟rolling medical students” who came on a rolling stand through Zoom, and they could see what we were doing and see the patient (7). We had virtual medical students and virtual patients at one time—both the learners and the patients were virtual. I would also lecture to a floating iPad. Grossman: To that point, your topic presentations on Facebook through the NANOS account have become something that a lot of people have learned from. How do you come up with the ideas for topics? Do you anticipate continuing to do that after COVID? Lee: Before COVID, the YouTube had around 8000 subscribers, but after COVID there are around 22000. Before COVID, we had 700,000 views, but now it is around 1.2 million views (7). COVID has perhaps given people a lot more time to binge watch these videos. In terms Grossman et al: J Neuro-Ophthalmol 2021; 41: 6-9 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Disease of the Year 2021: COVID-19 of the curriculum, it is whatever topic can fit within a short time frame. I rely on the comments on the videos for suggestions, and we try to do one every day (7). Galetta: We have seen a dramatic increase in attendance by our faculty and our residents because they do not have to be running to a conference room. I think a substantial amount of education will continue virtually. We have also held virtual regional neuro-ophthalmology conferences, bringing together the groups from Penn, Northwestern, and here at NYU. The fellows present cases to a whole group of attendings. We do that quarterly and it has been a lot of fun and very educational. So I think that this has opened up new educational opportunities, as Andy has described, to reach a broader group of people and has broadened our reach to interact with each other. Grossman: In talking to other trainees, many have noted that the barriers that traditionally separated institutions have fallen during this time. Do you expect that will be a challenge to continue going forward? If so, how would we be able to keep those channels of communication open such that they do not close as people go back to their “normal lives” after COVID? Lee: I think this is our new normal. I am not sure it is going to go back. But I think a lot of these things are going to become normal because it is going to be what trainees grew up with. Some of my medical students are going to graduate with 2 years of COVID under their belt, so I think they are just going to expect it. I do not think we can go back. Galetta: I totally concur with Andy. We were doing a lot of conferences over video because we have 4 hospitals that are geographically spread out. Residents used to be in the respective conference rooms together. This new technology allows people to be in their individual location. It makes it a lot more convenient and dramatically increases the participation. This is a substantial improvement in our connectivity. In addition, I could join Andy tomorrow in Houston and be the Visiting Professor for morning report and likewise him for us. We will probably do that more often because it would broaden the educational experience for everyone. We had a little bit of a taste with what we did with Northwestern and Penn, but it could be broadened. Grossman: Another thing I did like to touch on are national meetings such as NANOS, AAN, and AAO that have traditionally served many purposes. Of course, one of them was networking for trainees and junior faculty to meet leaders in the field and to enter the job market to look for a faculty position. Are you concerned that this aspect of national meetings will go by the wayside if everything becomes virtual? Galetta: I think it will be like the patients. You will have an option to have an in-person experience. I think most people who choose to do that will be for what you say. The social interactions are so important. It is a big part of any meeting, particularly NANOS. So I think 90% of people Grossman et al: J Neuro-Ophthalmol 2021; 41: 6-9 will come back to the meeting. But I think for some people a virtual meeting will be a convenient option for them, for reasons of expense and time. But I agree with you that it is very unfortunate right now that we cannot have face-to-face meetings and have the social fun that we all enjoy. Lee: At NANOS this year we are exploring a number of options that will allow virtual networking, including breakout rooms that people can go into if they want to have a private conversation. I think the technology is there it is just a matter of us getting used to a new way of networking. Certainly, all of our interviews for our residents and fellows will be virtual. At the beginning of these interviews it was very difficult. But I think we are going to get to the point where Zoom is going to be a normal thing for that social part too. For example, my family and I Zoom every week now, and I get to see them more than I did before COVID because we are so used to Zoom. Maybe this will be a new opportunity for what social networking looks like. Grossman: For fellows or residents who may be reading this, at NANOS this year there will be opportunities to do break-out sessions, networking, and to meet other neuroophthalmologists? Lee: Yes—it is all new for us on the planning side—but that is the opportunity and the challenge, how to create a networking opportunity that does not look like a lecture, but looks more like a party. Galetta: I think that is very tough. You know, we just had the American Neurological Association meeting and we had this type of arrangement where we had a Career Fair. Of course it was virtual, and people went into virtual rooms in that context. For NYU had a small number of people participate, but probably fewer than there would be if we actually had the live fair itself. In a general fair, you can browse and you can just go one booth to the next and you might see or hear something that is of interest. Unfortunately, the virtual format is very isolating and we felt it does not work as well. When you are with a group, you can back out, but without that group dynamic it is a bit awkward to do so. I think virtual fairs like this are an option, but they are a challenge. Maybe if the booze was flowing it would be easier, but I do not know if this will work going forward. Grossman: I think this will be substantially different going forward. For senior people it may not feel as if as much is lost because they are already in an established position, but I wonder about downstream effects for a generation of academic clinicians and researchers, whether we will be as interconnected as older generations have been during their careers if everything is virtual. Lee: I think it is interesting. My kid plays all these video games and they have avatars. You can literally walk into a room or give a hug or kiss even. And the avatars do it. Maybe that is where this is going? Your avatar will do the touching and handshaking. 7 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Disease of the Year 2021: COVID-19 Galetta: I hope not! Lee: That is what my kid does! She plays multiplayer games, where multiple players are in a game, and they do not look anything like what is on the screen, but they interact, even about mundane things. They are chatting like you would in person. Galetta: I think it is a second-best substitute. I am trying to touch you guys through the Zoom right now! Grossman: One of the other things that stands out to me about the 2 of you is that you are both also department chairs. In that role, it seems like you have to manage a lot of uncertainty, and that has been especially true during COVID, when people are trying to make plans about hiring decisions and the job search. Given this, I wondered if you had advice for trainees how to manage that degree of uncertainty during COVID with regard to career development. Lee: It is an uncertain time. It is hard to choose a job when you cannot be on-site to look around. There is no substitute. We have been interviewing a couple of people for jobs and you can tell they have no concept of what this place is like. We have gone to making videos now and they travel around as if you were interviewing from a point-of-view camera. This video has replaced our traditional slideshow for candidates. We have no onsite interviews for the position. Galetta: We have set up a Twitter account and created videos that tour the hospital and track the various teams during rounds. We have also asked our residents to create bios and pictures of themselves that highlight their interests and ask candidates to reach out to them individually. But it is not the same. I have been through a few of these, including heading a chair search during this period of time. We did the first several rounds by Zoom. It worked well to get it down to 2 candidates, but then those 2 candidates were invited for live interviews. This might be extreme, but all of the people underwent polymerase chain reaction testing that morning and the results came out within 2 hours. Then each of those people could meet face to face with the committee. It was kind of extreme but the people had to see the place and we had to see them in action, so I am in favor of going virtual to narrow it down and then coming together with masks and social distancing at the end. Grossman: A couple more questions about the Resident side. There were a number of people who got ‟drafted” into the medical intensive care unit or the emergency room to support COVID teams. Do you worry at all about adverse effects on the education in neurology or ophthalmology for those individuals who either volunteered or were drafted? Galetta: I do not think that people really lose all that much. In many ways it is arbitrary how long the residency is. It is more about competency than duration. I am not worried about it at all, especially if this is short-lived for 3 months. If we are talking about a year and a half of 3 years it may be a concern. But we will have ways to figure out if 8 they are competent. We use OSCEs a lot for our training program and that is one way to ensure competency. Grossman: Dr. Lee, how about from the ophthalmology side, for example, with procedural requirements for graduation? Lee: The accrediting bodies have allowed the numbers to be a little more flexible to account for this. We saw a drop [in case numbers] but we have not seen the kinds of numbers you have in New York. We did not have our residents pulled off to other services. I think that the New York ophthalmology residents may have a little more trouble, but I do not think anyone is going to hold them to those numbers. Grossman: We are nearing the end here so I would like to hear any other final comments you may have for residents or fellows who may be reading this. Lee: I would say that one of the things we lost was all our away rotators. Both people coming here and our trainees going elsewhere. It has dramatically affected our international programs. Luckily, after a set amount of time here in Houston, they let people quarantine and then start. I am sure there are neuro-ophthalmology fellowships that did not have a fellow this year because of travel restrictions. We also have heard of other fellows who came but then had to go back because of quarantine. Galetta: One of the things I learned that was humbling was that not everybody experienced the effects of the pandemic like I thought they did. There were circumstances that some people had that were very challenging. Superficially, you might think it was easier for them, but in fact it was harder for them. I think that going forward I am certainly going to be more mindful of those external factors that may affect people and their performance. One of those big topics is certainly childcare. That has been very difficult for people when we went virtual. You not only had to see your patients but you had to simultaneously be ‘mom and dad.’ That is not easy. On the other hand, if you are an intensivist or stroke doctor, you were seeing some of the most devastating changes in life situations that you have ever encountered in your life. So I think there is this psychosocial impact that we still don’t fully grasp and I think we have to be mindful of that (8). The second thing is that today is the day applications are released for [residency] program directors to review. We are going to learn a whole new set of parameters that are going to exist for virtual interviews. I think this is going to be a very unnatural experience and challenging for the applicants in particular. We have to do everything we can, as Andy said, to reach out to them and try to make them feel at home here. But it is not going to be the same. It is going to be difficult to take risks. Because you are not going to know that other place and you are not going to know where that place will stand when you start internship. I think people will tend to be conservative, and we might see reduced Grossman et al: J Neuro-Ophthalmol 2021; 41: 6-9 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Disease of the Year 2021: COVID-19 numbers of applications. Some people are predicting more applications, but we might have fewer applications. Grossman: I hear your point about being conservative in this era. Thanks so much to both of you for taking the time to do this, and stay well. REFERENCES 1. Chwalisz BK, Dinkin MJ. Disease of the year: COVID-19 and its neuro-ophthalmic complications. J Neuroophthalmol. 2020;40:283–284. 2. Lord AS, Lombardi N, Evans K, Deveaux D, Douglas E, Mansfield L, Zakin E, Jakubowska-Sadowska K, Grayson K, Omari M, Yaghi S, Humbert K, Sanger M, Kim S, Boffa M, Szuchumacher M, Jongeling A, Vazquez B, Abou-Fayssal N. Keeping the team together: transformation of an inpatient neurology service at an urban, multi-ethnic, safety net hospital in New York City during COVID-19. Clin Neurol Neurosurg. 2020;197:106156. 3. Grossman SN, Han SC, Balcer LJ, Kurzweil A, Weinberg H, Galetta SL, Busis NA. 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